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Journal for Specialists in Pediatric Nursing
ORIGINAL ARTICLE
Risk and associated factors of pressure ulcers in hospitalized children over 1 year of age Anna-Barbara Schlüer, Jos M. G. A. Schols, and Ruud J. G. Halfens Anna-Barbara Schlüer, MScN, is a Nurse Scientist at the Section of Nursing Science, Children’s Research Center, Children’s University Hospital Zurich, Zurich, Switzerland; Jos M. G. A. Schols, PhD, is Professor at the Departments of General Practice and Health Services Research, CAPHRI, Maastricht University; and Ruud J. G. Halfens, PhD, is an Associate Professor at the Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, The Netherlands
Search terms Infants and children, pediatric nursing, pressure ulcer, risk assessment, risk factor. Author contact [email protected], with a copy to the Editor: [email protected] Acknowledgement This research was partially supported by the Children’s University Hospital, Zurich, Switzerland, Section of Quality Management and Nursing Science. The authors would like to thank all the nursing staff members, as well as the chief nursing officers of all the hospitals involved for their active and interested participation in the study assessment. Further, we thank all the children and their families for their contribution. And we thank Dr. Heather Murray for her support in the revision of the English.
Abstract Purpose. This study aimed to identify factors for the development of pressure ulcers (PU) in hospitalized patients between 1 and 18 years of age. Design and Methods. A multicenter, descriptive, cross-sectional study in 13 hospitals was conducted in Switzerland. Results. The prevalence of PUs in this population of 204 children was 26.5%, with 83% category 1 PUs. A third of all PUs developed along external devices. Older children developed more PUs because of ineffective positioning and limited mobility. Practice Implications. It is important to assess each child’s activity, mobility, and the risk associated with the use of external devices.
Disclosure: The authors report no actual or potential conflicts of interest. First Received March 13, 2013; Final revision received October 1, 2013; Accepted for publication October 2, 2013. doi: 10.1111/jspn.12055
A pressure ulcer (PU) is a localized injury to the skin and/or underlying tissue as a result of pressure, or pressure in combination with shear forces (National Pressure Ulcer Advisory Panel [NPUAP] and European Pressure Ulcer Advisory Panel [EPUAP], 2009). Avoidance of pressure-related injuries and maintenance of skin and tissue integrity are important goals in the care process, and identifying individuals at risk of developing PUs by structured risk assessments is recommended as a first step for effective PU prevention (Stechmiller et al., 2008). 80
The NPUAP and EPUAP have published an international guideline (NPUAP & EPUAP, 2009), which explicitly states that “a structured approach may be achieved through the use of a risk assessment scale” in combination with clinical judgment (NPUAP & EPUAP, 2009, p. 10). While the problem of PUs has received a great deal of attention in adults, far less is known about PUs in children and neonates (Baharestani & Pope, 2007). Recent investigations have indicated that PUs are also common in the pediatric population: reported Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
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Risk and Associated Factors of Pressure Ulcers in Hospitalized Children Over 1 Year of Age
PU prevalence rates including all PU categories range from approximately 2% to 28% (Kottner, Wilborn, & Dassen, 2010) or 35% (Schlüer, Halfens, & Schols, 2012). One explanation for these high rates involves the dramatically improved survival rates of both critically and chronically ill infants and children, introducing new challenges for medical and nursing care (Jones, Tweed, & Marron, 2001). The skin may be affected because of external influences such as increased pressure and shear forces due to the application of external devices. Particularly in patients in pediatric intensive care units (PICUs), the influence of pressure by tubes for patients on oscillation and extracorporeal membrane oxygenation as well as their decreased tissue tolerance due to their critical life condition increase the risk of skin failure, making these patients most vulnerable for PUs (Baharestani & Pope, 2007; Curley, Razmus, Roberts, & Wypij, 2003; Schlüer et al., 2012). An adapted, reliable, and valid PU risk assessment tool with validated cutoff points, applicable for a wide range of the population from neonates to adolescents, is still not available (Anthony, Willock, & Baharestani, 2010; Kottner, Hauss, Schlüer, & Dassen, 2013). Because of the different risk factors in neonates, infants, and children, it does not seem feasible to develop a risk assessment tool for PU risk assessment covering a broad range of the pediatric population (Kottner et al., 2013). Many of the available assessment tools, like the Braden Q Scale, are modifications of PU risk scales for adults and include variables deemed especially important for PU development in the adult population; for example, mobility, incontinence, moisture, and nutrition. The relevance for clinical effectiveness of pediatric PU risk scales specifically has yet to be investigated (Kottner et al., 2013). Because of the specific lack of information about factors associated with PU risk in children of different age groups, there is an urgent need for studies on PUs in the pediatric population to obtain insight into the importance of the problem and to gain knowledge about child-specific risk and associated factors. Based on such studies, assessment with a specialized and standardized risk assessment tool as well as clinical judgment may lead to an improvement of the prevention of PUs and the quality of PU care for these patients. The aim of the present study was to identify factors associated with the occurrence of PUs in hospitalized pediatric patients between 1 and 18 years of age. Further, the aim was to identify anatomical Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
regions associated with the highest risk of PU occurrence and to identify risk factors of PUs in hospitalized pediatric patients. METHODS Study design
A multicenter, cross-sectional, descriptive study was conducted in 14 pediatric hospitals in the Germanspeaking area of Switzerland in June 2009 (Schlüer et al., 2012). Of this PU prevalence survey in hospitalized pediatric patients, the data for pediatric patients older than 1 year of age are presented here. Of the 14 pediatric hospitals that took part in the study, 13 had pediatric patients that met the inclusion criteria for this study. These hospitals had a total of 69 wards. All hospitalized children from 1 year of age up to 18 years were included in the study. Children had to be hospitalized for at least 1 day (Schlüer et al., 2012). Exclusion criteria were (a) hospitalization in psychiatric wards, (b) children whose legal representatives did not allow participation, and/or (c) children who refused to participate. The study was approved by all state ethics committees and when necessary, by the ethics board of the hospital concerned. After the patients and their legal representatives had been verbally informed about the study’s content and aim, they also received the information in written form along with an informed consent form to sign. The information letter as well as the informed consent form for the legal representatives was available in eight different languages (German, French, Italian, English, Portuguese, Albanian, Serbian, and Turkish). Children 10 years of age and older as well as their legal representatives/parents were both asked to give their written consent (Schlüer et al., 2012). Measurements
The instrument and method of data collection of the Dutch National Prevalence Measurement of Care Problems (LPZ) (Halfens et al., 2010) was used to assess the prevalence, severity, location, and risk factors, as well as factors associated with the occurrence of PUs. Associated factors included assessment of first occurrence of a PU and the setting in which a PU occurred. This information was taken from the patient’s chart. This instrument is widely used internationally and has been assessed as reliable and valid in adult patients (Bours, Halfens, Lubbers, & Haalboom, 1999). It comprises the following 81
Risk and Associated Factors of Pressure Ulcers in Hospitalized Children Over 1 Year of Age
categories of data for assessment: (a) patient characteristics (demographic and clinical data); (b) assessment of the location and severity of PUs; (c) PU risk assessment using the Braden Scale; (d) predisposing factors for PU development; (e) preventive interventions; as well as (f) therapeutic interventions. In addition to this instrument, we assessed all external devices on the patient’s body at the time of the assessment (e.g., tubes, intravenous [IV] catheterizations, continuous positive airway pressure [CPAP], splints/IV boards, and other devices), which might cause the occurrence of a PU in these children (Schlüer et al., 2012). The Braden Scale is part of the measurement tool and includes six subscales, five of which have four answer categories, and one only three (Bergstrom, Braden, Kemp, Champagne, & Ruby, 1998; Bergstrom, Braden, Laguzza, & Holman, 1987). The total possible scores range from 6 to 23 points, with a lower score indicating a higher risk for the patient to develop a PU. A cutoff point for patients at risk was set at ≤ 20 (Schlüer, Cignacco, Müller, & Halfens, 2009). Data collection
Data collection involved a direct and systematic inspection and judgment of the skin of the patient. Here, the NPUAP/EPUAP (NPUAP & EPUAP, 2009) PU category system was used. Demographic and clinical data, such as date of birth, weight and size, body mass index, and diagnosis, were collected from patient charts. Assessments of installations on the body site as well as other associated factors (like cloths and clothes, incorrect positioning, and cables in beds) that might lead to the development of PUs were clinically assessed. The total information was gathered both by direct inspection of the patient and from the patient files (Schlüer et al., 2012). Previously trained rater pairs gathered data for each patient. A total of 34 rater pairs were involved in the study. All raters were trained nurses with at least 2 years’ experience in working with neonates and infants. Preparatory training, given by the first author, included methodological aspects, detailed information about the data collection, the role and responsibilities of the raters, a detailed introduction to the measurement instruments, and special training in the grading of a PU in infants and children (Schlüer et al., 2012). For each hospital unit, an internal and an external rater worked together. The internal rater was from the unit itself, while the external rater was from another unit or department. If the pair disagreed on their assessment, they were 82
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asked to find consensus. If no consensus could be reached, the external rater was given the right to decide. No statement about disagreement within the rater pairs can be made as this was not an objective of the study. Pilot studies in all sites with more than two rater pairs were conducted to assess the interrater reliability for grading and risk assessment. The different rater pairs had to assess the same patients independently to check agreement or disagreement within the rater pairs in rating the category of PUs and use of the Braden Scale. A balanced incomplete block design was chosen (Fleiss, 1981). Overall, interrater reliability (Kappa 0.79: n = 180) for the grading of PUs was sufficient. A data consistency of 95% was observed as to whether the patient developed a PU or not. Data analysis
Predictive Analytics Software (version 18, formerly SPSS, SPSS Inc., Chicago, IL, USA) was used to analyze the study data with descriptive and univariate statistical methods. Explorative statistics were used (e.g., boxplots) to describe the distribution of the Braden score in relation to departments. Distributions and frequencies were calculated. The relationships between dependent variables and risk factors were distributed with cross tabs and calculated. Group differences were due to the type of data tested, with nonparametric tests for categorical (chi-square) and not normally distributed data (Wilcoxon). A p-value of .05 and lower was considered statistically significant. RESULTS Demographics
The overall sample size of potential study participants who met the inclusion criteria was 268 (100%). The total number of participants was 204 (76%) because 64 (24%) dropped out before the assessment. In 42 dropout cases (65%), either the legal representative or the child refused participation. Seventeen patients (30%) were excluded because of unexpected discharge from the hospital or because the examination or operation lasted longer than the survey period. Two children were not assessed because of an unexpected change in their condition to a critical level. Only three patients dropped out because of language problems. In the 13 hospitals, the participation rate ranged from 43% to 100%. Of the 204 assessed patients, 67% had been hospitalized for less than 14 Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
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Table 1. Demographic Characteristics of the Total Study Sample
Risk and Associated Factors of Pressure Ulcers in Hospitalized Children Over 1 Year of Age
Number of patients enrolled (%)
Characteristics Gender Male Age categories (years) 1–≤ 4 > 4–≤ 8 > 8–≤ 12 > 12 Department PICU Surgery Pediatric medical Rehabilitation Patients with at least one operation prior to observation Patients with medical devices (e.g., tubes, IV, and CPAP) Patients at risk (Braden score ≥ 20)
Length of hospital stay (days) Age (years)
113 (55.4) 60 (29.4) 42 (20.6) 41 (20.1) 61 (29.9) 10 (4.9) 82 (40.2) 84 (41.2) 28 (13.7) 91 (44.6) 149 (76.8) 65 (34)
Mean
Median
Range
SD
29.33 7.92
5 7.5
1–497 1–18
75.1 5.218
Note: Total n (%) = 204 (100). CPAP, continuous positive airway pressure; IV, intravenous; PICU, pediatric intensive care unit; SD, standard deviation.
days. In this subcategory, the average length of stay was 5 days, with a median of 3 days. The mean length of stay was 29 days (standard deviation [SD] = 75.1), with a median stay of 5 days (Table 1). A third of all children were under the age of 4 or older than 12 years of age (Table 1). Nearly 80% of all patients were hospitalized either in the surgical or the pediatric medical department, whereas only 5% were hospitalized in the PICU. Ninety-one patients (including PICU cases) had at least one operation during the hospitalization before the assessment (45%; Table 1).
and for those showing at least one PU. The highest percentage of patients were affected in the subcategory nutrition (score 1–3) with 45.6%, followed by activity with (score 1–3) 40.7%, mobility with (score 1–3) 33.8%, friction and shear forces with (score 1 + 2) 30.9%, and moisture with (score 1–3) 29.4%. Only 19.6% of all patients were affected in their sensory perception (score 1–3) (Table 3). It is interesting to note that patients at risk (Braden score of ≤ 20) as well as patients showing at least one PU had higher values in all subcategories of the Braden
PU risk
Table 2. Summary of Patients Showing PUs
The mean PU risk for all patients according to the Braden Scale was 20 (SD = 3.3), with a median of 22 and a range of 9–23. According to the Braden Scale, a total of 65 (32%) patients were assessed as being at risk (score of ≤ 20), with a mean of 16.5 and a median of 17 (SD = 2.8), whereas patients not at risk had a mean Braden score of 22 and a median of 23 (SD = 1.0; Tables 2 and 4). No significant differences were found between boys and girls (χ2 0.03; degrees of freedom [df] = 1; p = .43), whereas age (Wilcoxon rank sum test Z = −13.748, p < .001) and the type of department was significantly related to being at risk(χ2 25.8; df = 4; p < .001) (Table 4). Subcategories of Braden Scale
In Table 3, the subcategories of the Braden Scale are described for all patients as well as for patients at risk Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
Total patients with at least one PU (%) 54 (26.5) Gender Male Age categories (years) 1–≤ 4 > 4–≤ 8 > 8–≤ 12 > 12 Department PICU Surgery Pediatric medical Rehabilitation Patients with at least one operation prior to observation Patients with medical devices (e.g., tubes, IV, CPAP) Patients at risk (Braden score ≥ 20)
34 (63) 15 (28) 7 (13) 13 (24) 19 (35) 4 (40) 28 (34) 17 (20) 5 (18) 32 (59) 48 (89) 26 (49)
Note: CPAP, continuous positive airway pressure; IV, intravenous; PICU, pediatric intensive care unit; PU, pressure ulcer.
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Risk and Associated Factors of Pressure Ulcers in Hospitalized Children Over 1 Year of Age
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Table 3. Subcategories of the Braden Scale for the Whole Population Divided Into At-Risk and Not At-Risk Patients Subcategories of the Braden Scale
Categorization of each subscore
Patients not at risk n (%)
Patients at risk n (%)
n (%)
Sensory perception
Completely limited Very limited Slightly limited No impairment
0 0 1(8) 125 (76)
2 (100) 12 (100) 12 (92) 39 (24)
2 (1) 12 (5.9) 13 (6.4) 164 (80.4)
54.4/3*
Moisture
Constantly moist Very moist Constantly moist Rarely moist
0 0 16 (38) 110 (76)
0 5 (100) 26 (62) 34 (24)
0 5 (2.5) 42 (20.6) 144 (70.6)
31.2/3*
Activity
Bedfast Chair-fast Walks occasionally Walks frequently
0 0 12 (48) 114 (94)
30 (100) 15 (100) 13 (52) 7 (6)
30 (14.7) 15 (7.4) 25 (12.3) 121 (59.3)
113.8/3*
Mobility
Completely immobile Very limited Slightly limited No limitation
0 0 7 (25) 119 (88)
9 (100) 19 (100) 21 (75) 16 (12)
9 (4.4) 19 (9.3) 28 (13.7) 135 (66.2)
104.8/3*
Nutrition
Very poor Probably inadequate Adequate Excellent
0 12 (46) 32 (70) 82 (74)
8 (100) 14 (54) 14 (30) 29 (26)
8 (3.9) 26 (12.7) 46 (22.5) 111 (54.4)
23.4/3*
Friction and shear
Problem Potential problem No apparent problem
1 (7) 4 (11) 121 (86)
13 (93) 32 (89) 20 (14)
14 (6.9) 36 (17.6) 141 (69.1)
94.57/3*
χ2/df
Note: *Significant at p < .05. df, degrees of freedom.
Scale, except for nutrition and friction and shear, than patients who were not at risk or did not have a PU (Table 3). PU development, localization
A total of 54 patients showed at least one PU (26.5%; Table 2).The most frequently assessed PU category Table 4. PU Risk Assessed with the Braden Scale of the Total Study Sample and Differentiated Into Department, Sex, and Age Categories Total study sample Department Surgery (wards) Rehabilitation (three wards) Pediatric medical PICU Gender Male Female Age categories (years) 1–≤ 4 > 4–≤ 8 > 4–≤ 8 > 12
Mean
Median
SD
20
22
3.3
20 20 21 15
21 23 22 16
3.1 3.4 2.8 3.3
20 20
21 20
3 2
20 21 20 20
21 22 22 21
3.1 2.5 3.4 3.7
Note: PICU, pediatric intensive care unit; PU, pressure ulcer; SD, standard deviation.
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was category 1 (83.3%), but in one case a category 4 PU was assessed (Table 5). Most patients showed only one PU (n = 33), 12 patients showed two PUs, five patients showed three PUs, two patients showed four PUs, and one showed five or six PUs (Table 5). Most of the observed PUs had developed on the ward where the child was hospitalized during the measurement (68%; Table 6). In addition, most of the PUs had developed in the 2 weeks before the measurement (70.3%; Table 6). The lower Table 5. Frequency of PUs According to Category and Patients With One and More PU Total n (%) Number of PUs Category 1 Category 2 Category 3 Category 4 Patients with more than one PU 1 PU 2 PU 3 PU 4 PU 5 PU 6 PU
91 (100) 45 (83.3) 6 (11.1) 2 (3.7) 1 (1.9) 33 (61.1) 12 (22.2) 5 (9.3) 2 (3.7) 1 (1.9) 1 (1.9)
Note: PU, pressure ulcer.
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Risk and Associated Factors of Pressure Ulcers in Hospitalized Children Over 1 Year of Age
Table 6. Setting in Which PU Occurred, Point in Time and Localization of PU
Table 7. PUs Related to the Suspected Cause for the Development of PU
Setting in which PU occurred Unknown On the ward where the child was hospitalized External ward External hospital At home Residential home Point in time < 2 weeks 2 weeks to 3 months 3–6 months 6–12 months > 12 months Localization Differentiation Lower extremity Knees Feet Heels Toe Upper extremity Forearm Elbow Hand Sacrum, buttocks Bottom Sacrum Back Spinal Clavicular Head Ears Nasal septum Thorax/abdomen Others Total
Suspected cause
n (%)
Shear or pressure Splints due to IV catheterizationa Ineffective positioning Unknown Casta Intraoperative Clothes Tubea Oxygenation sensora Nasogastric tubea Neck collara Cables in bed Fixation Nasal O2 tubea Total
17 (18.7) 16 (17.6) 15 (16.5) 11 (12.1) 9 (9.9) 7 (7.7) 4 (4.4) 3 (3.3) 2 (2.2) 2 (2.2) 2 (2.2) 1 (1.1) 1 (1.1) 1 (1.1) 91 (100)
n (%) 10 (11) 67 (68) 7 (7.7) 4 (4.4) 6 (6.6) 2 (2.2) 64 (70.3) 17 (18.7) 7 (7.7) 1 (1.1) 2 (2.2) 35 (40.7) 5 (5.5) 31 (34.1) 23 (25.3) 4 (4.4) 21 (23.1) 6 (6.6) 4 (4.4) 11 (12.1) 16 (17.6) 6 (6.6) 4 (4.4) 5 (5.5) 2 (2.2) 10 (11) 3 (3.3) 5 (5.5) 5 (5.5) 5 (5.5) 91 (100)
Note: PU, pressure ulcer.
extremity and, of that, the foot (34.1%) was most often affected, followed by the upper extremity, most often the hand (12.1%). The sacral region including the hip followed by the head area was affected less frequently (Table 6). Most often, PUs developed as a result of external medical devices (n = 35, 38.5%; Table 7). DISCUSSION
In this study, hospitalized pediatric patients older than 1 year showed a PU prevalence rate of 26.5%. These patients presented with several factors that may have led to the development of a PU. First of all, the presence of medical devices seems to be a particular risk factor in all age categories. Second, in these patients, limited activity and mobility appeared to be particular risk factors as well. The Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
Note: aAll together summarized as external devices. IV, intravenous; PU, pressure ulcer.
most affected anatomical region for the development of a PU was the lower extremity, especially the foot. The PU prevalence of 26.5% in this study sample is rather high but in line with previous results reported (Schlüer et al., 2009; 28%). Older patients over the age of 12 years showed slightly more frequent PUs (32%) than children under the age of 8 years. Patients hospitalized in the PICU setting were most often affected by a PU (40%). Forty percent of the patients assessed as at risk (Braden score ≥ 20) showed a PU, whereas 32% of all patients with an external medical device showed at least one PU. Most of the PUs assessed in this study developed because of external devices (38.5%). This problem has long been recognized in infants and children (Okamoto, Lamers, & Shurtleff, 1983). In the development of risk assessment tools for the pediatric population, the risk factor “devices on the skin” has only become part of these scales since 1998 (Kottner et al., 2013). These devices on the skin are known as the most predominant risk factors of all for PUs in children and infants (Schlüer et al., 2012). However, the Braden Scale fails to include this potential risk factor. Therefore, in this study, external medical devices were additionally assessed. Young pediatric patients (under the age of 5 years) are, because of their developmental status, unable to properly differentiate pressure from other sensory perceptions of such devices and are therefore most vulnerable. Equipment-related risk factors, for example, those connected with traction, tubes, and IV catheterization, are therefore additional potential PU risk 85
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factors in the pediatric healthcare setting (Kottner et al., 2013; Noonan, Quigley, & Curley, 2006; Schlüer et al., 2009; Willock, Askew, Bolland, Maciver, & James, 2005). So far, the only published and tested pediatric PU risk assessment tool for the wide range of the child population (from 1–18 years), which includes the category “external devices on the skin” is the Glamorgan Scale (Willock, Anthony, & Richardson, 2008; Willock, Baharestani, & Anthony, 2007a, 2007b). It is indispensable to include this risk factor in PU risk assessment for pediatric patients in the future (Kottner et al., 2013). In this study, risk assessment was conducted using the Braden Scale. The use of the Braden Scale in a pediatric population in fact needs to be reflected upon critically. Although the Braden Scale is one of the best-known and widely used tools for evaluating PU risk in adults and the psychometric properties in assessing the PU risk of adults have been evaluated, there are still limited psychometric data available (Kottner, Raeder, Halfens, & Dassen, 2009; Moore & Cowman, 2008; Pancorbo-Hidalgo, GarciaFernandez, Lopez-Medina, & Alvarez-Nieto, 2006; Papanikolaou, Lyne, & Anthony, 2007). Thus, additional clinical judgment by experienced nurses is recommended (Papanikolaou et al., 2007). The original Braden Scale has not been validated for use in pediatric populations. Because this instrument is a risk scale for adults, it contains many variables deemed important for PU development in the adult population, such as incontinence, moisture, and nutrition, but, as mentioned, lacks potential specific risk factors for pediatric patients. Specificity and sensitivity for PU risk assessment in pediatric patients is therefore rather weak, and many patients with no specific risk potential for PU development are categorized as “at risk” (Schlüer et al., 2009, 2012). An adapted, reliable, and valid risk assessment tool, applicable to the wide age range from neonates to adolescents, in combination with validated cutoff points, is, however, not available for the pediatric population (Kottner et al., 2013). At the time of data collection for the present study, the common pediatric risk assessment scales available, like the Braden Q Scale and the Glamorgan Scale, were the bestknown PU risk assessment scales for the pediatric population (Curley et al., 2003; Kottner et al., 2013; Willock et al., 2007a, 2007b, 2008). The Braden Q, developed and introduced for immobile patients from 21 days of age, has not been validated for children more than 8 years of age, and no validated German version is available. There is also no vali86
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dated German version of the Glamorgan Scale. Because of this lack of possible alternative pediatric risk assessment tools in German and because the Braden Scale is part of the instrument used (LPZ), we decided to use the Braden Scale to describe potential risk factors in these pediatric patients. As stated by Kottner and colleagues (2013), the only indicator included in all pediatric specific risk assessment tools is mobility, which is also included in the Braden Scale. Because of the knowledge that devices represent a high risk of PU development, especially in younger children, we added the assessment of devices to the original instrument as stated in the methods section (Kottner et al., 2013; Willock, Harris, Harrison, & Poole, 2005, Willock et al., 2007a). The most frequent localization of a PU was the lower extremity, especially the feet (40%). The reason for this might be the fact that the majority of PUs was developed because of splints/IV boards or cables and sensors, as well as IV catheterization. Infants often have IV catheterization on the metatarsal or the ankle, additionally fixated by splints/IV boards. These splints/IV boards related to IV catheterization are suspected of causing the development of a PU in 18% of all PUs. Another frequently affected area is the upper extremity, especially the hand. In line with the suspected cause of PUs in the feet, another frequently used site for insertion of an IV catheter and additional fixation with splints/IV boards in children is the hand, especially the back of the hand. From the results of this study, the feet seem to be more at risk for PU development than the hand in small children. These findings require ongoing investigation to distinguish different factors that might elucidate this finding. Up to now, the ears, the occiput, heels and ischial tuberosities, and the nose are the anatomic sites in pediatric patients found to be most likely to develop a PU (Curley et al., 2003; Kottner et al., 2010; Schlüer et al., 2009; Suddaby, Barnett, & Facteau, 2005). However, this seems especially true for children under the age of 1 year, who were not included in this study, where the head area was only affected in 11% of those surveyed. Patients in PICUs most frequently developed PUs on the head, especially the face. This is in line with the fact that these children need numerous medical devices such as tubes, CPAP, and nasogastric tubes, which are attached to the face area. In this study, the number of patients treated in a PICU was relatively low with 10 patients (5%). Even the prevalence rate in PICU patients is high at 40% (n = 4), but this obviously needs further investigation. Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
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Risk and Associated Factors of Pressure Ulcers in Hospitalized Children Over 1 Year of Age
In our study, 18% of all PUs developed in the sacral region. This seems to contrast with studies of adult patients, where the sacral region is, next to the heel, most often affected (Kottner, Gefen, & Lahmann, 2011). These findings confirm the idea that the localization of PUs may differ between adult and pediatric patients. Further investigations along this line are needed. Additional potential risk factors for pediatric patients mentioned in the literature are immobility and decreased skin sensitivity (Suddaby et al., 2005; Willock, Askew, et al., 2005; Willock, Harris, et al., 2005). This study shows that 40% of all assessed children show a higher risk of PUs due to inactivity, immobilization, and nutrition when risk assessment is done with the Braden Scale. These findings are in line with previous studies (Huffines & Logsdon, 1997; Kottner et al., 2013), in which mobility is the only subcategory of assessment in all so-farpublished pediatric risk assessment tools (Kottner et al., 2013). In all, 40% of at-risk pediatric patients (meaning patients with a Braden Scale score ≤ 20) show at least one PU. This is slightly lower than the 49% reported for the pediatric population (neonates to 18 years) by Schlüer and colleagues (2012). Neonates and infants need intense treatment when admitted to the hospital, often involving external devices. Therefore, it seems possible that because of their immature and vulnerable skin within the first 12 months of life, neonates and infants are at general risk for PU occurrence. Thus, in this study, we included only children older than 1 year of age. Nutrition was a relevant risk factor in this study as well. Nutrition is known as a relevant factor with regard to skin integrity (Rodriguez-Key, 2007) in pediatric patients. To our best knowledge, no published clinical trials have examined the relationship between nutrition and PU occurrence; further investigation is warranted. Limitations
The study was conducted within 13 different pediatric hospitals; the participation rate varied between 43% and 100% by hospital. According to the ethical approval necessary for this study, patients older than 10 years of age had to sign their own informed consent as did their parents or legal representative. This meant that for all these patients, two informed consents were necessary. To what extent this procedure had an influence for patient participation remains unclear. Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
It is important to realize that prevalence studies are always subject to daily variations. However, in general, prevalence figures over the years are relatively constant (Gunningberg & Stotts, 2008). Most of the PUs in this study were category 1. To what extent the category 1 PUs were overdiagnosed or underdiagnosed in this study remains unclear, although the interrater reliability between the rater pairs suggests that the scores were reliable. The results of this study were gathered on one day and provide no information about the development of PUs in pediatric patients over time. The results of this study provide insight into the risk and associated factors that lead to the development of PUs in hospitalized pediatric patients older than 1 year. The use of the Braden Scale is of limited reliability because the original Braden Scale is not validated for use in pediatric populations. Because this instrument is a risk scale for adults, it contains many variables deemed important for PU development in the adult population, but it lacks potential specific risk factors for pediatric patients. Differences between adult and pediatric patients regarding the risk categories of the Braden Scale require further investigation. Moreover, the question arises whether it would not be feasible and necessary to develop a PU risk scale covering all the necessary aspects for the pediatric population. With regard to this, we added the assessment of medical devices in our study. To what extent these medical devices are the real cause for the PU occurrence in this study remains unclear. Because of the nature of the study, no causes of the development of PUs can be presented. Furthermore, no assumptions can be made about when the highest risk levels within a patient’s hospital stay occur, or which devices represent the highest risk of PU development. In this study, we only describe factors that might be associated with the occurrence of a PU in hospitalized pediatric patients older than 1 year. There is a need for longitudinal research in this population to determine at what times and within which settings pediatric patients most often develop PUs. CONCLUSIONS
PUs are a relevant care problem in children as well as in adults. This study showed that in children, the risk factors, the anatomical locations of PUs, as well as the risk of PUs due to external devices differ from those in an adult population. Therefore, specialized preventive interventions based on the needs of the pediatric population are mandatory. The use of risk 87
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assessment scales in pediatric health care should focus specifically on external medical devices and limited mobility and activity. Risk assessment scales for adults are not precise enough to cover pediatric risk factors. Age-related factors such as limited communication skills in children under the age of 2 years have not been addressed in any risk assessment tool so far. According to our findings, and in line with clinical expertise in the field of PU development in children, it is more reliable to focus on different risk populations, such as children hospitalized in a PICU, and also to assess equipment-related factors contributing to the development of PUs. Clinicians need to be aware of the particular PU risk potential of children and of the importance of decreasing preventable PUs. How might this information affect nursing practice?
Younger patients (under the age of 5 years) should be assessed carefully with regard to their inability to distinguish pressure on the skin adequately. Patients in the PICU setting seem most vulnerable to developing PUs in the face because of external devices on the skin. The risk assessment criterion “external devices to the skin” needs to be implemented in the pediatric setting and therefore evaluated in all age categories. Hospitalized children over the age of 1 year have to be assessed daily for their PU risk from decreased mobility and activity and from external medical devices. It is of key importance to develop and implement pediatric specific PU prevention guidelines and highlight risk factors for this population. References Anthony, D., Willock, J., & Baharestani, M. (2010). A comparison of Braden Q, Garvin, and Glamorgan risk assessment scales in paediatrics. Journal of Tissue Viability, 19(3), 98–105. doi:10.1016/j.jtv.2010.03.001 Baharestani, M. M., & Pope, E. (2007). Chronic wounds in neonates and children. In D. Krasner, G. Rodeheaver, & G. Sibbald (Eds.), Chronic wound care (pp. 679–693). Malvern, PA: HMP Communications. Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E. (1998). Predicting pressure ulcer risk: A multisite study of the predictive validity of the Braden Scale. Nursing Research, 47(5), 261–269. Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205–210.
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Bours, G. J., Halfens, R. J., Lubbers, M., & Haalboom, J. R. (1999). The development of a national registration form to measure the prevalence of pressure ulcers in the Netherlands. Ostomy/Wound Management, 45(11), 28–40. Curley, M. A., Razmus, I. S., Roberts, K. E., & Wypij, D. (2003). Predicting pressure ulcer risk in pediatric patients: The Braden-Q Scale. Nursing Research, 52(1), 22–33. Fleiss, J. (1981). Balanced incomplete block designs for inter-rater reliability studies. Applied Psychological Measurement, 5(1), 105–112. doi:10.1177/ 014662168100500115 Gunningberg, L., & Stotts, N. A. (2008). Tracking quality over time: What do pressure ulcer data show? International Journal for Quality in Health Care, 20(4), 246–253. doi:10.1093/intqhc/mzn009 Halfens, R., Schols, J., Meesterbrends, E., Meijers, J., Neyens, J., van Nie, N., . . . Wolters, S. (2010). The Dutch National Prevalence Survey of Care Problems. Retrieved January 21, 2012 from http://www.lpz-um.eu/eng/ about-lpz Huffines, B., & Logsdon, M. C. (1997). The Neonatal Skin Risk Assessment Scale for predicting skin breakdown in neonates. Issues in Comprehensive Pediatric Nursing, 20(2), 103–114. Jones, I., Tweed, C., & Marron, M. (2001). Pressure area care in infants and children: Nimbus Paediatric System. British Journal of Nursing, 10(12), 789–795. Kottner, J., Gefen, A., & Lahmann, N. (2011). Weight and pressure ulcer occurrence: A secondary data analysis. International Journal of Nursing Studies, 48(11), 1339–1348. doi:10.1016/j.ijnurstu.2011.04.011 Kottner, J., Hauss, A., Schlüer, A.-B., & Dassen, T. (2013). Validation and clinical impact of paediatric pressure ulcer risk assessment scales: A systematic review. International Journal of Nursing Studies, 50(6), 807–818. doi:10.1016/j.ijnurstu.2011.04.014 Kottner, J., Raeder, K., Halfens, R., & Dassen, T. (2009). A systematic review of interrater reliability of pressure ulcer classification systems. Journal of Clinical Nursing, 18(3), 315–336. doi:10.1111/j.1365.2702.2008.02569.x Kottner, J., Wilborn, D., & Dassen, T. (2010). Frequency of pressure ulcers in the paediatric population: A literature review and new empirical data. International Journal of Nursing Studies, 47(10), 1330–1340. doi:10.1016/ j.ijnurstu.2010.07.006 Moore, Z. E., & Cowman, S. (2008). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, (3), CD006471. doi:10.1002/ 14651858.CD006471.pub2 National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel.
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Noonan, C., Quigley, S., & Curley, M. A. (2006). Skin integrity in hospitalized infants and children: A prevalence survey. Journal of Pediatric Nursing, 21(6), 445–453. Okamoto, G. A., Lamers, J. V., & Shurtleff, D. B. (1983). Skin breakdown in patients with myelomeningocele. Archives of Physical Medicine and Rehabilitation, 64(1), 20–23. Pancorbo-Hidalgo, P. L., Garcia-Fernandez, F. P., Lopez-Medina, I. M., & Alvarez-Nieto, C. (2006). Risk assessment scales for pressure ulcer prevention: A systematic review. Journal of Advanced Nursing, 54(1), 94–110. Papanikolaou, P., Lyne, P., & Anthony, D. (2007). Risk assessment scales for pressure ulcers: A methodological review. International Journal of Nursing Studies, 44(2), 285–296. Rodriguez-Key, M., & Alonzi, A. (2007). Nutrition, skin integrity and pressure ulcer healing in chronically ill children: An overview. Ostomy Wound Management, 53(6), 56–66. Schlüer, A. B., Cignacco, E., Müller, M., & Halfens, R. J. (2009). The prevalence of pressure ulcers in four pediatric institutions. Journal of Clinical Nursing, 18(23), 3244–3252. doi:10.1111/j.1365-2702.2009.02951.x Schlüer, A.-B., Halfens, R. J., & Schols, J. M. G. A. (2012). Pediatric pressure ulcer prevalence: A multicenter,
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cross-sectional, point prevalence study in Switzerland. Ostomy/Wound Management, 58(7), 18–31. Stechmiller, J. K., Cowan, L., Whitney, J. D., Phillips, L., Aslam, R., Barbul, A., . . . Stotts, N. (2008). Guidelines for the prevention of pressure ulcers. Wound Repair and Regeneration, 16(2), 151–168. doi:10.1111/j.1524-475X .2008.00356.x Suddaby, E. C., Barnett, S., & Facteau, L. (2005). Skin breakdown in acute care pediatrics. Pediatric Nursing, 31(2), 132–138. Willock, J., Anthony, D., & Richardson, J. (2008). Inter-rater reliability of the Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale. Paediatric Nursing, 20(7), 14–19. Willock, J., Askew, C., Bolland, R., Maciver, H., & James, N. (2005). Multicenter research: Lessons from the field. Paediatric Nursing, 17(10), 31–33. Willock, J., Baharestani, M., & Anthony, D. (2007a). A risk assessment scale for pressure ulcers in children. Nursing Times, 103(14), 32–33. Willock, J., Baharestani, M. M., & Anthony, D. (2007b). The development of the Glamorgan paediatric pressure ulcer risk assessment scale. Journal of Children’s and Young People’s Nursing, 01(5), 211–218. Willock, J., Harris, C., Harrison, J., & Poole, C. (2005). Identifying the characteristics of children with pressure ulcers. Nursing Times, 101(11), 40–43.
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ORIGINAL ARTICLE
Risk and associated factors of pressure ulcers in hospitalized children over 1 year of age Anna-Barbara Schlüer, Jos M. G. A. Schols, and Ruud J. G. Halfens Anna-Barbara Schlüer, MScN, is a Nurse Scientist at the Section of Nursing Science, Children’s Research Center, Children’s University Hospital Zurich, Zurich, Switzerland; Jos M. G. A. Schols, PhD, is Professor at the Departments of General Practice and Health Services Research, CAPHRI, Maastricht University; and Ruud J. G. Halfens, PhD, is an Associate Professor at the Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, The Netherlands
Search terms Infants and children, pediatric nursing, pressure ulcer, risk assessment, risk factor. Author contact [email protected], with a copy to the Editor: [email protected] Acknowledgement This research was partially supported by the Children’s University Hospital, Zurich, Switzerland, Section of Quality Management and Nursing Science. The authors would like to thank all the nursing staff members, as well as the chief nursing officers of all the hospitals involved for their active and interested participation in the study assessment. Further, we thank all the children and their families for their contribution. And we thank Dr. Heather Murray for her support in the revision of the English.
Abstract Purpose. This study aimed to identify factors for the development of pressure ulcers (PU) in hospitalized patients between 1 and 18 years of age. Design and Methods. A multicenter, descriptive, cross-sectional study in 13 hospitals was conducted in Switzerland. Results. The prevalence of PUs in this population of 204 children was 26.5%, with 83% category 1 PUs. A third of all PUs developed along external devices. Older children developed more PUs because of ineffective positioning and limited mobility. Practice Implications. It is important to assess each child’s activity, mobility, and the risk associated with the use of external devices.
Disclosure: The authors report no actual or potential conflicts of interest. First Received March 13, 2013; Final revision received October 1, 2013; Accepted for publication October 2, 2013. doi: 10.1111/jspn.12055
A pressure ulcer (PU) is a localized injury to the skin and/or underlying tissue as a result of pressure, or pressure in combination with shear forces (National Pressure Ulcer Advisory Panel [NPUAP] and European Pressure Ulcer Advisory Panel [EPUAP], 2009). Avoidance of pressure-related injuries and maintenance of skin and tissue integrity are important goals in the care process, and identifying individuals at risk of developing PUs by structured risk assessments is recommended as a first step for effective PU prevention (Stechmiller et al., 2008). 80
The NPUAP and EPUAP have published an international guideline (NPUAP & EPUAP, 2009), which explicitly states that “a structured approach may be achieved through the use of a risk assessment scale” in combination with clinical judgment (NPUAP & EPUAP, 2009, p. 10). While the problem of PUs has received a great deal of attention in adults, far less is known about PUs in children and neonates (Baharestani & Pope, 2007). Recent investigations have indicated that PUs are also common in the pediatric population: reported Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
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PU prevalence rates including all PU categories range from approximately 2% to 28% (Kottner, Wilborn, & Dassen, 2010) or 35% (Schlüer, Halfens, & Schols, 2012). One explanation for these high rates involves the dramatically improved survival rates of both critically and chronically ill infants and children, introducing new challenges for medical and nursing care (Jones, Tweed, & Marron, 2001). The skin may be affected because of external influences such as increased pressure and shear forces due to the application of external devices. Particularly in patients in pediatric intensive care units (PICUs), the influence of pressure by tubes for patients on oscillation and extracorporeal membrane oxygenation as well as their decreased tissue tolerance due to their critical life condition increase the risk of skin failure, making these patients most vulnerable for PUs (Baharestani & Pope, 2007; Curley, Razmus, Roberts, & Wypij, 2003; Schlüer et al., 2012). An adapted, reliable, and valid PU risk assessment tool with validated cutoff points, applicable for a wide range of the population from neonates to adolescents, is still not available (Anthony, Willock, & Baharestani, 2010; Kottner, Hauss, Schlüer, & Dassen, 2013). Because of the different risk factors in neonates, infants, and children, it does not seem feasible to develop a risk assessment tool for PU risk assessment covering a broad range of the pediatric population (Kottner et al., 2013). Many of the available assessment tools, like the Braden Q Scale, are modifications of PU risk scales for adults and include variables deemed especially important for PU development in the adult population; for example, mobility, incontinence, moisture, and nutrition. The relevance for clinical effectiveness of pediatric PU risk scales specifically has yet to be investigated (Kottner et al., 2013). Because of the specific lack of information about factors associated with PU risk in children of different age groups, there is an urgent need for studies on PUs in the pediatric population to obtain insight into the importance of the problem and to gain knowledge about child-specific risk and associated factors. Based on such studies, assessment with a specialized and standardized risk assessment tool as well as clinical judgment may lead to an improvement of the prevention of PUs and the quality of PU care for these patients. The aim of the present study was to identify factors associated with the occurrence of PUs in hospitalized pediatric patients between 1 and 18 years of age. Further, the aim was to identify anatomical Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
regions associated with the highest risk of PU occurrence and to identify risk factors of PUs in hospitalized pediatric patients. METHODS Study design
A multicenter, cross-sectional, descriptive study was conducted in 14 pediatric hospitals in the Germanspeaking area of Switzerland in June 2009 (Schlüer et al., 2012). Of this PU prevalence survey in hospitalized pediatric patients, the data for pediatric patients older than 1 year of age are presented here. Of the 14 pediatric hospitals that took part in the study, 13 had pediatric patients that met the inclusion criteria for this study. These hospitals had a total of 69 wards. All hospitalized children from 1 year of age up to 18 years were included in the study. Children had to be hospitalized for at least 1 day (Schlüer et al., 2012). Exclusion criteria were (a) hospitalization in psychiatric wards, (b) children whose legal representatives did not allow participation, and/or (c) children who refused to participate. The study was approved by all state ethics committees and when necessary, by the ethics board of the hospital concerned. After the patients and their legal representatives had been verbally informed about the study’s content and aim, they also received the information in written form along with an informed consent form to sign. The information letter as well as the informed consent form for the legal representatives was available in eight different languages (German, French, Italian, English, Portuguese, Albanian, Serbian, and Turkish). Children 10 years of age and older as well as their legal representatives/parents were both asked to give their written consent (Schlüer et al., 2012). Measurements
The instrument and method of data collection of the Dutch National Prevalence Measurement of Care Problems (LPZ) (Halfens et al., 2010) was used to assess the prevalence, severity, location, and risk factors, as well as factors associated with the occurrence of PUs. Associated factors included assessment of first occurrence of a PU and the setting in which a PU occurred. This information was taken from the patient’s chart. This instrument is widely used internationally and has been assessed as reliable and valid in adult patients (Bours, Halfens, Lubbers, & Haalboom, 1999). It comprises the following 81
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categories of data for assessment: (a) patient characteristics (demographic and clinical data); (b) assessment of the location and severity of PUs; (c) PU risk assessment using the Braden Scale; (d) predisposing factors for PU development; (e) preventive interventions; as well as (f) therapeutic interventions. In addition to this instrument, we assessed all external devices on the patient’s body at the time of the assessment (e.g., tubes, intravenous [IV] catheterizations, continuous positive airway pressure [CPAP], splints/IV boards, and other devices), which might cause the occurrence of a PU in these children (Schlüer et al., 2012). The Braden Scale is part of the measurement tool and includes six subscales, five of which have four answer categories, and one only three (Bergstrom, Braden, Kemp, Champagne, & Ruby, 1998; Bergstrom, Braden, Laguzza, & Holman, 1987). The total possible scores range from 6 to 23 points, with a lower score indicating a higher risk for the patient to develop a PU. A cutoff point for patients at risk was set at ≤ 20 (Schlüer, Cignacco, Müller, & Halfens, 2009). Data collection
Data collection involved a direct and systematic inspection and judgment of the skin of the patient. Here, the NPUAP/EPUAP (NPUAP & EPUAP, 2009) PU category system was used. Demographic and clinical data, such as date of birth, weight and size, body mass index, and diagnosis, were collected from patient charts. Assessments of installations on the body site as well as other associated factors (like cloths and clothes, incorrect positioning, and cables in beds) that might lead to the development of PUs were clinically assessed. The total information was gathered both by direct inspection of the patient and from the patient files (Schlüer et al., 2012). Previously trained rater pairs gathered data for each patient. A total of 34 rater pairs were involved in the study. All raters were trained nurses with at least 2 years’ experience in working with neonates and infants. Preparatory training, given by the first author, included methodological aspects, detailed information about the data collection, the role and responsibilities of the raters, a detailed introduction to the measurement instruments, and special training in the grading of a PU in infants and children (Schlüer et al., 2012). For each hospital unit, an internal and an external rater worked together. The internal rater was from the unit itself, while the external rater was from another unit or department. If the pair disagreed on their assessment, they were 82
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asked to find consensus. If no consensus could be reached, the external rater was given the right to decide. No statement about disagreement within the rater pairs can be made as this was not an objective of the study. Pilot studies in all sites with more than two rater pairs were conducted to assess the interrater reliability for grading and risk assessment. The different rater pairs had to assess the same patients independently to check agreement or disagreement within the rater pairs in rating the category of PUs and use of the Braden Scale. A balanced incomplete block design was chosen (Fleiss, 1981). Overall, interrater reliability (Kappa 0.79: n = 180) for the grading of PUs was sufficient. A data consistency of 95% was observed as to whether the patient developed a PU or not. Data analysis
Predictive Analytics Software (version 18, formerly SPSS, SPSS Inc., Chicago, IL, USA) was used to analyze the study data with descriptive and univariate statistical methods. Explorative statistics were used (e.g., boxplots) to describe the distribution of the Braden score in relation to departments. Distributions and frequencies were calculated. The relationships between dependent variables and risk factors were distributed with cross tabs and calculated. Group differences were due to the type of data tested, with nonparametric tests for categorical (chi-square) and not normally distributed data (Wilcoxon). A p-value of .05 and lower was considered statistically significant. RESULTS Demographics
The overall sample size of potential study participants who met the inclusion criteria was 268 (100%). The total number of participants was 204 (76%) because 64 (24%) dropped out before the assessment. In 42 dropout cases (65%), either the legal representative or the child refused participation. Seventeen patients (30%) were excluded because of unexpected discharge from the hospital or because the examination or operation lasted longer than the survey period. Two children were not assessed because of an unexpected change in their condition to a critical level. Only three patients dropped out because of language problems. In the 13 hospitals, the participation rate ranged from 43% to 100%. Of the 204 assessed patients, 67% had been hospitalized for less than 14 Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
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Table 1. Demographic Characteristics of the Total Study Sample
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Number of patients enrolled (%)
Characteristics Gender Male Age categories (years) 1–≤ 4 > 4–≤ 8 > 8–≤ 12 > 12 Department PICU Surgery Pediatric medical Rehabilitation Patients with at least one operation prior to observation Patients with medical devices (e.g., tubes, IV, and CPAP) Patients at risk (Braden score ≥ 20)
Length of hospital stay (days) Age (years)
113 (55.4) 60 (29.4) 42 (20.6) 41 (20.1) 61 (29.9) 10 (4.9) 82 (40.2) 84 (41.2) 28 (13.7) 91 (44.6) 149 (76.8) 65 (34)
Mean
Median
Range
SD
29.33 7.92
5 7.5
1–497 1–18
75.1 5.218
Note: Total n (%) = 204 (100). CPAP, continuous positive airway pressure; IV, intravenous; PICU, pediatric intensive care unit; SD, standard deviation.
days. In this subcategory, the average length of stay was 5 days, with a median of 3 days. The mean length of stay was 29 days (standard deviation [SD] = 75.1), with a median stay of 5 days (Table 1). A third of all children were under the age of 4 or older than 12 years of age (Table 1). Nearly 80% of all patients were hospitalized either in the surgical or the pediatric medical department, whereas only 5% were hospitalized in the PICU. Ninety-one patients (including PICU cases) had at least one operation during the hospitalization before the assessment (45%; Table 1).
and for those showing at least one PU. The highest percentage of patients were affected in the subcategory nutrition (score 1–3) with 45.6%, followed by activity with (score 1–3) 40.7%, mobility with (score 1–3) 33.8%, friction and shear forces with (score 1 + 2) 30.9%, and moisture with (score 1–3) 29.4%. Only 19.6% of all patients were affected in their sensory perception (score 1–3) (Table 3). It is interesting to note that patients at risk (Braden score of ≤ 20) as well as patients showing at least one PU had higher values in all subcategories of the Braden
PU risk
Table 2. Summary of Patients Showing PUs
The mean PU risk for all patients according to the Braden Scale was 20 (SD = 3.3), with a median of 22 and a range of 9–23. According to the Braden Scale, a total of 65 (32%) patients were assessed as being at risk (score of ≤ 20), with a mean of 16.5 and a median of 17 (SD = 2.8), whereas patients not at risk had a mean Braden score of 22 and a median of 23 (SD = 1.0; Tables 2 and 4). No significant differences were found between boys and girls (χ2 0.03; degrees of freedom [df] = 1; p = .43), whereas age (Wilcoxon rank sum test Z = −13.748, p < .001) and the type of department was significantly related to being at risk(χ2 25.8; df = 4; p < .001) (Table 4). Subcategories of Braden Scale
In Table 3, the subcategories of the Braden Scale are described for all patients as well as for patients at risk Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
Total patients with at least one PU (%) 54 (26.5) Gender Male Age categories (years) 1–≤ 4 > 4–≤ 8 > 8–≤ 12 > 12 Department PICU Surgery Pediatric medical Rehabilitation Patients with at least one operation prior to observation Patients with medical devices (e.g., tubes, IV, CPAP) Patients at risk (Braden score ≥ 20)
34 (63) 15 (28) 7 (13) 13 (24) 19 (35) 4 (40) 28 (34) 17 (20) 5 (18) 32 (59) 48 (89) 26 (49)
Note: CPAP, continuous positive airway pressure; IV, intravenous; PICU, pediatric intensive care unit; PU, pressure ulcer.
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Table 3. Subcategories of the Braden Scale for the Whole Population Divided Into At-Risk and Not At-Risk Patients Subcategories of the Braden Scale
Categorization of each subscore
Patients not at risk n (%)
Patients at risk n (%)
n (%)
Sensory perception
Completely limited Very limited Slightly limited No impairment
0 0 1(8) 125 (76)
2 (100) 12 (100) 12 (92) 39 (24)
2 (1) 12 (5.9) 13 (6.4) 164 (80.4)
54.4/3*
Moisture
Constantly moist Very moist Constantly moist Rarely moist
0 0 16 (38) 110 (76)
0 5 (100) 26 (62) 34 (24)
0 5 (2.5) 42 (20.6) 144 (70.6)
31.2/3*
Activity
Bedfast Chair-fast Walks occasionally Walks frequently
0 0 12 (48) 114 (94)
30 (100) 15 (100) 13 (52) 7 (6)
30 (14.7) 15 (7.4) 25 (12.3) 121 (59.3)
113.8/3*
Mobility
Completely immobile Very limited Slightly limited No limitation
0 0 7 (25) 119 (88)
9 (100) 19 (100) 21 (75) 16 (12)
9 (4.4) 19 (9.3) 28 (13.7) 135 (66.2)
104.8/3*
Nutrition
Very poor Probably inadequate Adequate Excellent
0 12 (46) 32 (70) 82 (74)
8 (100) 14 (54) 14 (30) 29 (26)
8 (3.9) 26 (12.7) 46 (22.5) 111 (54.4)
23.4/3*
Friction and shear
Problem Potential problem No apparent problem
1 (7) 4 (11) 121 (86)
13 (93) 32 (89) 20 (14)
14 (6.9) 36 (17.6) 141 (69.1)
94.57/3*
χ2/df
Note: *Significant at p < .05. df, degrees of freedom.
Scale, except for nutrition and friction and shear, than patients who were not at risk or did not have a PU (Table 3). PU development, localization
A total of 54 patients showed at least one PU (26.5%; Table 2).The most frequently assessed PU category Table 4. PU Risk Assessed with the Braden Scale of the Total Study Sample and Differentiated Into Department, Sex, and Age Categories Total study sample Department Surgery (wards) Rehabilitation (three wards) Pediatric medical PICU Gender Male Female Age categories (years) 1–≤ 4 > 4–≤ 8 > 4–≤ 8 > 12
Mean
Median
SD
20
22
3.3
20 20 21 15
21 23 22 16
3.1 3.4 2.8 3.3
20 20
21 20
3 2
20 21 20 20
21 22 22 21
3.1 2.5 3.4 3.7
Note: PICU, pediatric intensive care unit; PU, pressure ulcer; SD, standard deviation.
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was category 1 (83.3%), but in one case a category 4 PU was assessed (Table 5). Most patients showed only one PU (n = 33), 12 patients showed two PUs, five patients showed three PUs, two patients showed four PUs, and one showed five or six PUs (Table 5). Most of the observed PUs had developed on the ward where the child was hospitalized during the measurement (68%; Table 6). In addition, most of the PUs had developed in the 2 weeks before the measurement (70.3%; Table 6). The lower Table 5. Frequency of PUs According to Category and Patients With One and More PU Total n (%) Number of PUs Category 1 Category 2 Category 3 Category 4 Patients with more than one PU 1 PU 2 PU 3 PU 4 PU 5 PU 6 PU
91 (100) 45 (83.3) 6 (11.1) 2 (3.7) 1 (1.9) 33 (61.1) 12 (22.2) 5 (9.3) 2 (3.7) 1 (1.9) 1 (1.9)
Note: PU, pressure ulcer.
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Table 6. Setting in Which PU Occurred, Point in Time and Localization of PU
Table 7. PUs Related to the Suspected Cause for the Development of PU
Setting in which PU occurred Unknown On the ward where the child was hospitalized External ward External hospital At home Residential home Point in time < 2 weeks 2 weeks to 3 months 3–6 months 6–12 months > 12 months Localization Differentiation Lower extremity Knees Feet Heels Toe Upper extremity Forearm Elbow Hand Sacrum, buttocks Bottom Sacrum Back Spinal Clavicular Head Ears Nasal septum Thorax/abdomen Others Total
Suspected cause
n (%)
Shear or pressure Splints due to IV catheterizationa Ineffective positioning Unknown Casta Intraoperative Clothes Tubea Oxygenation sensora Nasogastric tubea Neck collara Cables in bed Fixation Nasal O2 tubea Total
17 (18.7) 16 (17.6) 15 (16.5) 11 (12.1) 9 (9.9) 7 (7.7) 4 (4.4) 3 (3.3) 2 (2.2) 2 (2.2) 2 (2.2) 1 (1.1) 1 (1.1) 1 (1.1) 91 (100)
n (%) 10 (11) 67 (68) 7 (7.7) 4 (4.4) 6 (6.6) 2 (2.2) 64 (70.3) 17 (18.7) 7 (7.7) 1 (1.1) 2 (2.2) 35 (40.7) 5 (5.5) 31 (34.1) 23 (25.3) 4 (4.4) 21 (23.1) 6 (6.6) 4 (4.4) 11 (12.1) 16 (17.6) 6 (6.6) 4 (4.4) 5 (5.5) 2 (2.2) 10 (11) 3 (3.3) 5 (5.5) 5 (5.5) 5 (5.5) 91 (100)
Note: PU, pressure ulcer.
extremity and, of that, the foot (34.1%) was most often affected, followed by the upper extremity, most often the hand (12.1%). The sacral region including the hip followed by the head area was affected less frequently (Table 6). Most often, PUs developed as a result of external medical devices (n = 35, 38.5%; Table 7). DISCUSSION
In this study, hospitalized pediatric patients older than 1 year showed a PU prevalence rate of 26.5%. These patients presented with several factors that may have led to the development of a PU. First of all, the presence of medical devices seems to be a particular risk factor in all age categories. Second, in these patients, limited activity and mobility appeared to be particular risk factors as well. The Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
Note: aAll together summarized as external devices. IV, intravenous; PU, pressure ulcer.
most affected anatomical region for the development of a PU was the lower extremity, especially the foot. The PU prevalence of 26.5% in this study sample is rather high but in line with previous results reported (Schlüer et al., 2009; 28%). Older patients over the age of 12 years showed slightly more frequent PUs (32%) than children under the age of 8 years. Patients hospitalized in the PICU setting were most often affected by a PU (40%). Forty percent of the patients assessed as at risk (Braden score ≥ 20) showed a PU, whereas 32% of all patients with an external medical device showed at least one PU. Most of the PUs assessed in this study developed because of external devices (38.5%). This problem has long been recognized in infants and children (Okamoto, Lamers, & Shurtleff, 1983). In the development of risk assessment tools for the pediatric population, the risk factor “devices on the skin” has only become part of these scales since 1998 (Kottner et al., 2013). These devices on the skin are known as the most predominant risk factors of all for PUs in children and infants (Schlüer et al., 2012). However, the Braden Scale fails to include this potential risk factor. Therefore, in this study, external medical devices were additionally assessed. Young pediatric patients (under the age of 5 years) are, because of their developmental status, unable to properly differentiate pressure from other sensory perceptions of such devices and are therefore most vulnerable. Equipment-related risk factors, for example, those connected with traction, tubes, and IV catheterization, are therefore additional potential PU risk 85
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factors in the pediatric healthcare setting (Kottner et al., 2013; Noonan, Quigley, & Curley, 2006; Schlüer et al., 2009; Willock, Askew, Bolland, Maciver, & James, 2005). So far, the only published and tested pediatric PU risk assessment tool for the wide range of the child population (from 1–18 years), which includes the category “external devices on the skin” is the Glamorgan Scale (Willock, Anthony, & Richardson, 2008; Willock, Baharestani, & Anthony, 2007a, 2007b). It is indispensable to include this risk factor in PU risk assessment for pediatric patients in the future (Kottner et al., 2013). In this study, risk assessment was conducted using the Braden Scale. The use of the Braden Scale in a pediatric population in fact needs to be reflected upon critically. Although the Braden Scale is one of the best-known and widely used tools for evaluating PU risk in adults and the psychometric properties in assessing the PU risk of adults have been evaluated, there are still limited psychometric data available (Kottner, Raeder, Halfens, & Dassen, 2009; Moore & Cowman, 2008; Pancorbo-Hidalgo, GarciaFernandez, Lopez-Medina, & Alvarez-Nieto, 2006; Papanikolaou, Lyne, & Anthony, 2007). Thus, additional clinical judgment by experienced nurses is recommended (Papanikolaou et al., 2007). The original Braden Scale has not been validated for use in pediatric populations. Because this instrument is a risk scale for adults, it contains many variables deemed important for PU development in the adult population, such as incontinence, moisture, and nutrition, but, as mentioned, lacks potential specific risk factors for pediatric patients. Specificity and sensitivity for PU risk assessment in pediatric patients is therefore rather weak, and many patients with no specific risk potential for PU development are categorized as “at risk” (Schlüer et al., 2009, 2012). An adapted, reliable, and valid risk assessment tool, applicable to the wide age range from neonates to adolescents, in combination with validated cutoff points, is, however, not available for the pediatric population (Kottner et al., 2013). At the time of data collection for the present study, the common pediatric risk assessment scales available, like the Braden Q Scale and the Glamorgan Scale, were the bestknown PU risk assessment scales for the pediatric population (Curley et al., 2003; Kottner et al., 2013; Willock et al., 2007a, 2007b, 2008). The Braden Q, developed and introduced for immobile patients from 21 days of age, has not been validated for children more than 8 years of age, and no validated German version is available. There is also no vali86
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dated German version of the Glamorgan Scale. Because of this lack of possible alternative pediatric risk assessment tools in German and because the Braden Scale is part of the instrument used (LPZ), we decided to use the Braden Scale to describe potential risk factors in these pediatric patients. As stated by Kottner and colleagues (2013), the only indicator included in all pediatric specific risk assessment tools is mobility, which is also included in the Braden Scale. Because of the knowledge that devices represent a high risk of PU development, especially in younger children, we added the assessment of devices to the original instrument as stated in the methods section (Kottner et al., 2013; Willock, Harris, Harrison, & Poole, 2005, Willock et al., 2007a). The most frequent localization of a PU was the lower extremity, especially the feet (40%). The reason for this might be the fact that the majority of PUs was developed because of splints/IV boards or cables and sensors, as well as IV catheterization. Infants often have IV catheterization on the metatarsal or the ankle, additionally fixated by splints/IV boards. These splints/IV boards related to IV catheterization are suspected of causing the development of a PU in 18% of all PUs. Another frequently affected area is the upper extremity, especially the hand. In line with the suspected cause of PUs in the feet, another frequently used site for insertion of an IV catheter and additional fixation with splints/IV boards in children is the hand, especially the back of the hand. From the results of this study, the feet seem to be more at risk for PU development than the hand in small children. These findings require ongoing investigation to distinguish different factors that might elucidate this finding. Up to now, the ears, the occiput, heels and ischial tuberosities, and the nose are the anatomic sites in pediatric patients found to be most likely to develop a PU (Curley et al., 2003; Kottner et al., 2010; Schlüer et al., 2009; Suddaby, Barnett, & Facteau, 2005). However, this seems especially true for children under the age of 1 year, who were not included in this study, where the head area was only affected in 11% of those surveyed. Patients in PICUs most frequently developed PUs on the head, especially the face. This is in line with the fact that these children need numerous medical devices such as tubes, CPAP, and nasogastric tubes, which are attached to the face area. In this study, the number of patients treated in a PICU was relatively low with 10 patients (5%). Even the prevalence rate in PICU patients is high at 40% (n = 4), but this obviously needs further investigation. Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
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In our study, 18% of all PUs developed in the sacral region. This seems to contrast with studies of adult patients, where the sacral region is, next to the heel, most often affected (Kottner, Gefen, & Lahmann, 2011). These findings confirm the idea that the localization of PUs may differ between adult and pediatric patients. Further investigations along this line are needed. Additional potential risk factors for pediatric patients mentioned in the literature are immobility and decreased skin sensitivity (Suddaby et al., 2005; Willock, Askew, et al., 2005; Willock, Harris, et al., 2005). This study shows that 40% of all assessed children show a higher risk of PUs due to inactivity, immobilization, and nutrition when risk assessment is done with the Braden Scale. These findings are in line with previous studies (Huffines & Logsdon, 1997; Kottner et al., 2013), in which mobility is the only subcategory of assessment in all so-farpublished pediatric risk assessment tools (Kottner et al., 2013). In all, 40% of at-risk pediatric patients (meaning patients with a Braden Scale score ≤ 20) show at least one PU. This is slightly lower than the 49% reported for the pediatric population (neonates to 18 years) by Schlüer and colleagues (2012). Neonates and infants need intense treatment when admitted to the hospital, often involving external devices. Therefore, it seems possible that because of their immature and vulnerable skin within the first 12 months of life, neonates and infants are at general risk for PU occurrence. Thus, in this study, we included only children older than 1 year of age. Nutrition was a relevant risk factor in this study as well. Nutrition is known as a relevant factor with regard to skin integrity (Rodriguez-Key, 2007) in pediatric patients. To our best knowledge, no published clinical trials have examined the relationship between nutrition and PU occurrence; further investigation is warranted. Limitations
The study was conducted within 13 different pediatric hospitals; the participation rate varied between 43% and 100% by hospital. According to the ethical approval necessary for this study, patients older than 10 years of age had to sign their own informed consent as did their parents or legal representative. This meant that for all these patients, two informed consents were necessary. To what extent this procedure had an influence for patient participation remains unclear. Journal for Specialists in Pediatric Nursing 1 (2014) 80–89 © 2013, Wiley Periodicals, Inc.
It is important to realize that prevalence studies are always subject to daily variations. However, in general, prevalence figures over the years are relatively constant (Gunningberg & Stotts, 2008). Most of the PUs in this study were category 1. To what extent the category 1 PUs were overdiagnosed or underdiagnosed in this study remains unclear, although the interrater reliability between the rater pairs suggests that the scores were reliable. The results of this study were gathered on one day and provide no information about the development of PUs in pediatric patients over time. The results of this study provide insight into the risk and associated factors that lead to the development of PUs in hospitalized pediatric patients older than 1 year. The use of the Braden Scale is of limited reliability because the original Braden Scale is not validated for use in pediatric populations. Because this instrument is a risk scale for adults, it contains many variables deemed important for PU development in the adult population, but it lacks potential specific risk factors for pediatric patients. Differences between adult and pediatric patients regarding the risk categories of the Braden Scale require further investigation. Moreover, the question arises whether it would not be feasible and necessary to develop a PU risk scale covering all the necessary aspects for the pediatric population. With regard to this, we added the assessment of medical devices in our study. To what extent these medical devices are the real cause for the PU occurrence in this study remains unclear. Because of the nature of the study, no causes of the development of PUs can be presented. Furthermore, no assumptions can be made about when the highest risk levels within a patient’s hospital stay occur, or which devices represent the highest risk of PU development. In this study, we only describe factors that might be associated with the occurrence of a PU in hospitalized pediatric patients older than 1 year. There is a need for longitudinal research in this population to determine at what times and within which settings pediatric patients most often develop PUs. CONCLUSIONS
PUs are a relevant care problem in children as well as in adults. This study showed that in children, the risk factors, the anatomical locations of PUs, as well as the risk of PUs due to external devices differ from those in an adult population. Therefore, specialized preventive interventions based on the needs of the pediatric population are mandatory. The use of risk 87
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assessment scales in pediatric health care should focus specifically on external medical devices and limited mobility and activity. Risk assessment scales for adults are not precise enough to cover pediatric risk factors. Age-related factors such as limited communication skills in children under the age of 2 years have not been addressed in any risk assessment tool so far. According to our findings, and in line with clinical expertise in the field of PU development in children, it is more reliable to focus on different risk populations, such as children hospitalized in a PICU, and also to assess equipment-related factors contributing to the development of PUs. Clinicians need to be aware of the particular PU risk potential of children and of the importance of decreasing preventable PUs. How might this information affect nursing practice?
Younger patients (under the age of 5 years) should be assessed carefully with regard to their inability to distinguish pressure on the skin adequately. Patients in the PICU setting seem most vulnerable to developing PUs in the face because of external devices on the skin. The risk assessment criterion “external devices to the skin” needs to be implemented in the pediatric setting and therefore evaluated in all age categories. Hospitalized children over the age of 1 year have to be assessed daily for their PU risk from decreased mobility and activity and from external medical devices. It is of key importance to develop and implement pediatric specific PU prevention guidelines and highlight risk factors for this population. References Anthony, D., Willock, J., & Baharestani, M. (2010). A comparison of Braden Q, Garvin, and Glamorgan risk assessment scales in paediatrics. Journal of Tissue Viability, 19(3), 98–105. doi:10.1016/j.jtv.2010.03.001 Baharestani, M. M., & Pope, E. (2007). Chronic wounds in neonates and children. In D. Krasner, G. Rodeheaver, & G. Sibbald (Eds.), Chronic wound care (pp. 679–693). Malvern, PA: HMP Communications. Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E. (1998). Predicting pressure ulcer risk: A multisite study of the predictive validity of the Braden Scale. Nursing Research, 47(5), 261–269. Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205–210.
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Bours, G. J., Halfens, R. J., Lubbers, M., & Haalboom, J. R. (1999). The development of a national registration form to measure the prevalence of pressure ulcers in the Netherlands. Ostomy/Wound Management, 45(11), 28–40. Curley, M. A., Razmus, I. S., Roberts, K. E., & Wypij, D. (2003). Predicting pressure ulcer risk in pediatric patients: The Braden-Q Scale. Nursing Research, 52(1), 22–33. Fleiss, J. (1981). Balanced incomplete block designs for inter-rater reliability studies. Applied Psychological Measurement, 5(1), 105–112. doi:10.1177/ 014662168100500115 Gunningberg, L., & Stotts, N. A. (2008). Tracking quality over time: What do pressure ulcer data show? International Journal for Quality in Health Care, 20(4), 246–253. doi:10.1093/intqhc/mzn009 Halfens, R., Schols, J., Meesterbrends, E., Meijers, J., Neyens, J., van Nie, N., . . . Wolters, S. (2010). The Dutch National Prevalence Survey of Care Problems. Retrieved January 21, 2012 from http://www.lpz-um.eu/eng/ about-lpz Huffines, B., & Logsdon, M. C. (1997). The Neonatal Skin Risk Assessment Scale for predicting skin breakdown in neonates. Issues in Comprehensive Pediatric Nursing, 20(2), 103–114. Jones, I., Tweed, C., & Marron, M. (2001). Pressure area care in infants and children: Nimbus Paediatric System. British Journal of Nursing, 10(12), 789–795. Kottner, J., Gefen, A., & Lahmann, N. (2011). Weight and pressure ulcer occurrence: A secondary data analysis. International Journal of Nursing Studies, 48(11), 1339–1348. doi:10.1016/j.ijnurstu.2011.04.011 Kottner, J., Hauss, A., Schlüer, A.-B., & Dassen, T. (2013). Validation and clinical impact of paediatric pressure ulcer risk assessment scales: A systematic review. International Journal of Nursing Studies, 50(6), 807–818. doi:10.1016/j.ijnurstu.2011.04.014 Kottner, J., Raeder, K., Halfens, R., & Dassen, T. (2009). A systematic review of interrater reliability of pressure ulcer classification systems. Journal of Clinical Nursing, 18(3), 315–336. doi:10.1111/j.1365.2702.2008.02569.x Kottner, J., Wilborn, D., & Dassen, T. (2010). Frequency of pressure ulcers in the paediatric population: A literature review and new empirical data. International Journal of Nursing Studies, 47(10), 1330–1340. doi:10.1016/ j.ijnurstu.2010.07.006 Moore, Z. E., & Cowman, S. (2008). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, (3), CD006471. doi:10.1002/ 14651858.CD006471.pub2 National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel.
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Noonan, C., Quigley, S., & Curley, M. A. (2006). Skin integrity in hospitalized infants and children: A prevalence survey. Journal of Pediatric Nursing, 21(6), 445–453. Okamoto, G. A., Lamers, J. V., & Shurtleff, D. B. (1983). Skin breakdown in patients with myelomeningocele. Archives of Physical Medicine and Rehabilitation, 64(1), 20–23. Pancorbo-Hidalgo, P. L., Garcia-Fernandez, F. P., Lopez-Medina, I. M., & Alvarez-Nieto, C. (2006). Risk assessment scales for pressure ulcer prevention: A systematic review. Journal of Advanced Nursing, 54(1), 94–110. Papanikolaou, P., Lyne, P., & Anthony, D. (2007). Risk assessment scales for pressure ulcers: A methodological review. International Journal of Nursing Studies, 44(2), 285–296. Rodriguez-Key, M., & Alonzi, A. (2007). Nutrition, skin integrity and pressure ulcer healing in chronically ill children: An overview. Ostomy Wound Management, 53(6), 56–66. Schlüer, A. B., Cignacco, E., Müller, M., & Halfens, R. J. (2009). The prevalence of pressure ulcers in four pediatric institutions. Journal of Clinical Nursing, 18(23), 3244–3252. doi:10.1111/j.1365-2702.2009.02951.x Schlüer, A.-B., Halfens, R. J., & Schols, J. M. G. A. (2012). Pediatric pressure ulcer prevalence: A multicenter,
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cross-sectional, point prevalence study in Switzerland. Ostomy/Wound Management, 58(7), 18–31. Stechmiller, J. K., Cowan, L., Whitney, J. D., Phillips, L., Aslam, R., Barbul, A., . . . Stotts, N. (2008). Guidelines for the prevention of pressure ulcers. Wound Repair and Regeneration, 16(2), 151–168. doi:10.1111/j.1524-475X .2008.00356.x Suddaby, E. C., Barnett, S., & Facteau, L. (2005). Skin breakdown in acute care pediatrics. Pediatric Nursing, 31(2), 132–138. Willock, J., Anthony, D., & Richardson, J. (2008). Inter-rater reliability of the Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale. Paediatric Nursing, 20(7), 14–19. Willock, J., Askew, C., Bolland, R., Maciver, H., & James, N. (2005). Multicenter research: Lessons from the field. Paediatric Nursing, 17(10), 31–33. Willock, J., Baharestani, M., & Anthony, D. (2007a). A risk assessment scale for pressure ulcers in children. Nursing Times, 103(14), 32–33. Willock, J., Baharestani, M. M., & Anthony, D. (2007b). The development of the Glamorgan paediatric pressure ulcer risk assessment scale. Journal of Children’s and Young People’s Nursing, 01(5), 211–218. Willock, J., Harris, C., Harrison, J., & Poole, C. (2005). Identifying the characteristics of children with pressure ulcers. Nursing Times, 101(11), 40–43.
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